Provider Demographics
NPI:1629508940
Name:MARTIN, STEPHEN MYCHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MYCHAEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W 31ST ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-5850
Mailing Address - Country:US
Mailing Address - Phone:708-323-5654
Mailing Address - Fax:
Practice Address - Street 1:16739 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-6018
Practice Address - Country:US
Practice Address - Phone:708-418-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012748A1223G0001X
IL019.0311961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice